Post-Menopausal AUB

Question 1

definition of PMB

Answer 1

any bleed 1 year after menstruation stops

Question 2

causes of PMB

Answer 2

cylic hormone therapy (or continuous - rare)

endometrial or vulvovaginal atrophy = most commont

endometrial cancer (10-15%)
endo hyperplasia
endo or cervical polyps
ectropion
other malignancy: cervix, vag, uterine sarcoma, fallopian tube/ovary

bleeding from GU or GI

coagulation disorder

Question 3

evaluation of PMB

Answer 3

history
physical - pelvic
endometrial biopsy
cervix or vagina biopsy if lesions
endocervical curettage if clinical concern re Ca there

TVUS = adjunct - r/o other pathology, measure thickness.

Question 4

endo biopsy techniques

Answer 4

endometrial sampling - local anaesthesia in office, +/- miso

if unable or discomfort: hysteroscopy + D+C /w GA, or if endo biopsy inadequate or negative but bleeding continues

Question 5

abnormal thickness of endometrial

Answer 5

5mm or more
- may still have type II Ca if less

5+ = Ca, adenomyosis, polyps, fibroids, tamoxifen effect

Question 6

Risk Factors for Endometrial Cancer

Answer 6

• age: 95% are over 40
• excessive estrogen /w out progesterone
• obesity, nulliparity, early onset menarche, late onset menopause, E only therapy
• tamoxifen - antiestrogen for BC, has estrogenic effect on endo, but minimal risk
• rare: granulosa or theca cell ovary tumour, HNPCC/lynch

obesity = most important, then E therapy

Question 7

Type 1 endometrial cancer clinical features

Answer 7

• hx unopposed E
• diagnosed early b/c AUB + seen on biopsy
• ususally endometrioid adenocarcinoma
• superfifically invasive
• good prognosis
• surgery alone can cure

Question 8

type 2 endometrial cancer clinical features

Answer 8

• non estrogen related
• p53 mutation common
• more in African American
• more advanced
• aggressive histology (papillary serous, clear cell, deep invasive, poor differentiated adenocarcinoma)
• +/- early AUB

Question 9

classification of endometrial hyperplasia + chance of transformation

Answer 9

cystic (simple)
adenomatous (complex)
1-4%, usually anov states

atypical - 25%, and 30-40% are malignant after surgical dx

Question 10

endometrial cancers types

Answer 10

endometrioid adenocarcinoma - most common

papillary serous

clear cell

mucinous adenocarcinoma = uncommon

Question 11

uterine sarcoma types

Answer 11

all rare - poor prognosis, spread far, advanced at dx

leiomyosarcoma

endometrial stromal sarcoma

undifferentiated sarcoma

Question 12

FIGO staging (surgical)

Answer 12

stage I - in corpus uteri

Stage II - into cervical stroma

Stage III - local/regional in serosa, gyne or nodes

Stage IV - bladder, bowel mucosa or distant mets

Question 13

other (not stage) RF for poor prognosis

Answer 13

grade

histo subtype clear or serous

capillary like spaces / LVSI (esp if deep myometrial invasion)

older age

positive peritoneal cytology

Question 14

treatment of endometrial ca

Answer 14

Total hyst + BSO, staging surgical

stage I - no other tx unless bad histo, multiple poor prognositc factors, esp if not all nodes taken out

stage II - adjuvant radiation, external pelvic + brachy vaginal

stage III - individualized, rad + chemo

stage IVB (distant mets) or recurrent – palliative (radiation for AUB, combo chemo increase survival length, or progesterone (esp if +ve for receptors)

Question 15

surgical staging technique

Answer 15

inspect + palpate peritoneum + biopsy lesions, cytology of wash, pelvic + para-aortic nodes

+/- omenectomy + complete lymphadenectomy… controversy, do if high risk histology

can be laparoscopic